My new book, "Health, Medicine and Justice: Designing a fair and equitable healthcare system", is out and and widely available!
Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Thursday, December 30, 2010

.I sit in Arizona at Christmas, finishing Dennis Lehane’s novel “The Given Day”[1]. Set in 1919 in Boston and culminating in the landmark Boston police strike of that year, Lehane documents the “red scare” of that period, accompanied by the real number and strength of “reds”, the overt racism of the period along with the early days of the NAACP, the early days of the labor movement, the early days of John E. Hoover and the BI (later, of course, J. Edgar and the FBI), all set to a backdrop of the mid-career of Babe Ruth and the Red Sox (and his ultimate move to the New York Yankees). But from here, in Tucson, what seems most relevant today is that it documents the massive immigration (at that time in Boston mostly of Italians, Russians, and Jews) and anti-immigrant sentiment that accompanied it. So our current anti-immigrant furor is nothing new. It has deep roots, and is now, as it always has been, misguided.

Of course, American anti-immigrant movements go back much farther than 1919. Before the Russians, Italians, and Jews of the late 19th and early 20th century. Before even the Irish immigration, the xenophobic reaction to which was dramatically shown in the 2002 Martin Scorsese film “The Gangs of New York”. Before the Germans, back to the Alien and Sedition Acts of the John Adams administration at the end of the 18th century, and probably before that. Every group of European immigrants I have mentioned and more, Asians from China, Japan and the Philippines, and many others, have been vilified in their time. Each has been attacked by those already here, and ready to raise the drawbridge behind them. And they have made America great.

They come to America to escape grinding poverty or to maximize their opportunity. Most are poor, but some are doctors and engineers who believe they can do even better here than in, say India or Africa. (This is another issue, of brain drain, which I have touched on in earlier posts). Every time there are those “nativists” (some not here long themselves) who want to close the door, who worry that “they” will take “our” jobs. In Lehane’s book immigrants are leaders of the unions (as well as the radical revolutionary groups); immigrants have always mainly been workers. And is it different now, as the main focus of anti-immigrant wrath are those from Mexico? The wrath is centered here in Arizona (although, it should be noted, the sentiment is not uniform; although only symbolic, the Tucson City Council voted to oppose the state anti-immigrant law), and felt not only in the Southwest but all over the country. Does it make a difference that so many Mexican immigrants are “illegal”? Many of our citizens have been illegal. The major secondary characters in “The Given Day”, two older policemen who enforce “order” for the “Big Money” folks, came to the US from Ireland as teens, stowing away on a ship, and literally escaping into the streets of Boston, before later joining the force. Illegals, certainly, who believed themselves to be more "American" than the current generation of immigrants. And fictional, but representative of many real-life characters. Many “illegals” became citizens after serving in our armed forces, especially in World War II, when “we” needed “them”. Of course, America always needs “them”, to build our cities, our railroads, or industries; to be our engineers and storekeepers and cops and firemen and packing-house workers. We are “them”.

And we remain them, and they us, with only few exceptions. American Indians, whose “immigration” may have been in pre-history, and African-Americans, brought here in bondage, arguably the two most oppressed and discriminated-against ethnic groups. We can no more honorably close the door now than the descendants of English colonists who stole Indian land could for the Germans, or Irish, or Chinese, or Russian, or Polish, or Filipino, or Italian, or Jewish immigrants who succeeded them. They have always been the ones who did the work. Who pay taxes (so they are not caught) but receive no benefits, because we pass laws against “illegal” immigrants – denying them health care, denying them safety. Yet they are here; they get sick and injured, in working two and three jobs. And paying into benefit funds such as pensions and Social Security and Medicare for those of us, from earlier immigrations, to retire on, and receive our health care from. We can pass a health reform law that specifically excludes them from health coverage, not even allowing them to buy with their own money, but they will still need health care. We can even, in a gesture worthy of the persecutions of the 1920s, not pass the “Dream Act” so people who were brought up in this country can attend college with their classmates. Vigilantes can “patrol” the border, and fascist thugs like Maricopa County Sheriff Arpaio can terrorize entire communities. We can pass laws that make it a crime to help save the life of a person found dying in the desert. We can talk of children born to immigrant parents as “anchor babies”, and here I need to refer people to Lalo Alcaraz’ Christmas Day cartoon in his strip “La Cucaracha”. We can, and do, do all sorts of mean, short-sighted, and selfish things to oppress people, but this does not make them wise, honorable, moral, or even sensible. We can, however, be better than that.

In the coming year, I hope the Dream Act passes. And I hope that we can define ourselves, as Americans and as human beings, by our wisdom, our foresight, and the nobler parts of our nature, rather than by our narrowness, meaness, and bigotry.

Friday, December 24, 2010

.Turns out that Baltimore may be the McAllen, Texas of cardiac stents. An article published On Monday, December 6, 2010 in the NY Times, “Doctor faces suits over cardiac stents”, by Gardiner Harris, describes the case of Dr. Mark Midei of Baltimore, who is now the target of a Senate Finance Committee investigation following a series of articles in the Baltimore Sun alleging that he put cardiac stents in many people who did not need them. Dr. Midei apparently put in as many as 30 stents per day, 1200 stents per year, in his hospital – numbers that matched hospitals 4 and 5 time as large in the northeast, and the Senate report indicates at least 585 were medically unnecessary, for which he charged Medicare $6.6M and was paid $3.8M. While the hospital, St. Joseph, is also being sued, apparently it and Dr. Midei are accusing each other of being at fault, and of trying to destroy each others’ reputations. Meanwhile, Abbott Laboratories, which manufactures the devices, is lavishing millions of dollars in favors upon Dr. Midei, a small portion of the enormous revenue he has generated for them. The report says that “The serious allegations lodged against Dr. Midei regarding the medically unnecessary implantation of cardiac stents did not appear to deter Abbott’s interest in assisting him.”

There is a lot more to say about this particular case, including a great quote: “After one particularly critical story in The Baltimore Sun, David C. Pacitti, an Abbott executive, wrote in an e-mail, ‘Someone needs to take this writer out and kick his ass.’”, but it would be a mistake to focus too much on this one; there are a lot more corrupt doctors, hospitals, and drug and device manufacturers (Abbott is both) out there.

First, the evidence. While the Times article cites “A landmark 2007 study published in The New England Journal of Medicine showed that many patients given stents would fare just as well without them,” they don’t indicate the article they are referring to (no author or reference given; the link is not to the article), but presumably it is the Swedish study by Lagerkvist, et. al, that showed increased recurrent MI (heart attack) and death with the use of drug-eluting stents compared to bare metal stents.[1] However, there are several articles in the March 8, 2007 issue of NEJM that address the safety of drug-eluting stents (i.e., stents impregnated with a drug to keep them from getting re-clotted, which as a group do not provide a consistent picture. Spaulding, et. al., from Paris, found that there was no difference in outcomes from patients with stents with the drug sirolimus compared to bare metal[2], while Stone and colleagues from Columbia found that drug-eluting stents with both sirolimus and paclitaxel had greater rates of re-thrombosis (though not heart attack or death) than bare metal.[3] Meanwhile, Kastrati and colleagues from Germany, reviewing 14 studies of sirolimus-eluting stents, also found no increase or decrease in heart attack or death, but less need for re-intervention, although at least as much re-thrombosis (clotting) as bare metal stents.[4] There are also two editorials; Farb and Boam, the official one from FDA[5] conclude “The safety and effectiveness of drug-eluting stents as compared with those of alternative treatments deserve continued study.”, while Maisel, head of an FDA committee that reviews these devices, writes “Drug-eluting stents represent an important advance in the management of coronary artery disease and have benefited many patients.“[6]

None of these articles compared stents to no stents, and there is no question that that many, many patients with coronary artery disease benefit greatly from them, getting relief of symptoms without having their chests cut open for surgery (coronary artery bypass grafting, or CABG, pronounced “cabbage”. Cute, huh?). Drug-eluting stents now require the patient take an anti-coagulant, and so the complex decision of whether they are better than bare-metal must be made for an individual patient, based on a variety of patient, stent, and anti-coagulation-risk characteristics. It is also worth noting that either stents or CABG only bypass (or stent open) already-narrowed areas in the coronary arteries. Therefore the risk of recurrent heart attack (MI) and associated death is not only from re-stenosis but the rupture of a cholesterol-laden plaque that might not previously been causing significant obstruction. These are the “sudden” MIs, which account for a larger number of heart attacks than those that come after increasing, gradual narrowing of a coronary artery (and the associated increasing chest pain, called angina pectoris).

Probably even more important are the complex interplay of financial rewards and government regulation that impact on the use of these and other devices, as well as all kinds of other treatments and interventions. There can be no justification for the obviously excessive stent placement by Dr. Midei, or the encouragement of it by Abbott and probably the hospital; as the Times article notes ”… far from questioning cardiologists who perform an unusually high number of stent procedures, many hospital executives celebrate these doctors because of the revenue they bring, which can be more than $10,000 per procedure.” In this context, the reported statement of Senator Max Baucus, Democrat of Montana and chairman of the Finance Committee, that “Hospital patients expect their care to be based on medical need, not profits…Even more disconcerting is that this could be a sign of a larger national trend of wasteful medical device use,” sounds heroic, but is it?

The hospitals have a point too, in their criticism of government regulation. Not all of the investigations by HHS, Medicare, and other government agencies are really meant to uncover such gross overuse or fraud, although this is how they are portrayed. Many of them are just about getting money for the Federal government as aggressively as possible, and if it can be called “fraud” as opposed to a “mistake” they can get huge penalties as well as refunds of Medicare money spent. A major Medicare initiative is Recovery Audit Contractors (RACs), essentially bounty hunters given a license to investigate certain hospitals for fraud. Great, except most of their work seems to be on finding whether patients were (and this is going to seem like a technical subtlety) officially “admitted” to the hospital, when the severity of their illness could have allowed them to be placed in the hospital for a day or more on “observation” status, where they are officially outpatients and reimbursed at a lower rate. If a hospital or doctor were systematically admitting people who should obviously be “observed”, this might be real fraud, what are probably honest minor errors (or differences of opinion) in the assessment of patient condition are blown up so that the RAC (and Medicare) can recover big penalties. Far from trying to systematically defraud Medicare, my hospital, the University of Kansas Hospital (which is very happy with its high cardiac-care rating by US News and is truly one of those hospitals that enjoy the large amounts of money interventional cardiology procedures provide) is spending a bunch of money to have each admission audited by an outside firm to ensure that they don’t violate these criteria and make themselves vulnerable to RAC recoveries.

So who is the “white hat”? Certainly not the drug and device makers, who are really “only in it for the money”, often not the hospitals, and sadly not always (although, honestly, most of the time) the doctors. But also not the government, seeking money to fund its wars in a down economy. Senator Baucus, famous for taking huge amounts from drug companies himself, may not be the one whom we should be trusting, but his statement that “Hospital patients [and, I would add, all patients!] expect their care to be based on medical need, not profits” is certainly a sentiment that I would endorse. Of course, the making of these profits is why the drug companies paid him. Some suspect that this might be partly why his committee, and the Congress overall, and the administration, did not pass a health reform bill that would achieve that result. Fraud is bad, and uncovering fraud is good, but RACs are not an answer to a flawed, profit-driven, health system.

Saturday, December 18, 2010

.Criticisms of the new health law, the Affordable Care Act (ACA), have come from all sides. While many of them are justified, they also miss many of the law’s positives. It doesn’t assure the reliable, cost-controlled security of a real universal health insurance program, but it will lead to coverage of tens of millions of more Americans, and will eliminate the ability of insurance companies to engage in health risk underwriting, the practice that allows them to deny coverage to those with pre-existing conditions. These are points that the President made in his recent interview on Jon Stewart’s Daily Show. "Individual mandates", i.e., forcing everyone to buy insurance, while it is a touchstone for the right and is the issue found unconstitutional by a Virginia federal judge (and which will probably go to the Supreme Court), was the price that insurance companies demanded for assuring coverage for everyone. As I have often written, you have to have all the healthy people in if you are going to cover the sick; there are many more healthy, but all of us can become sick.

Apparently, a lot of people understand this. A recent poll by Marist College and McClatchy newspapers shows a majority (51%, but still a majority) of Americans want to continue (16%) or increase (35%) the benefits of ACA, with 44% going the other direction. “Among groups with pluralities who want to expand it: women, minorities, people younger than 45, Democrats, liberals, Northeasterners and those making less than $50,000 a year. Lining up against the law, 11 percent want to amend it to rein it in; 33 percent want to repeal it. Among groups with pluralities favoring repeal: men, whites, those older than 45, those making more than $50,000 annually, conservatives, Republicans and tea party supporters.” OK, these are the “usual suspects”, except that it amazing and saddening to me that older people who are receiving Medicare can be opposed to expanding benefits to others. Maybe they are just ignorant of Medicare and the current law (as reflected in “Keep the government’s hands off my Medicare!”); this is also sad, but would explain what would otherwise be an enormously, almost immoral, selfishness. Yes, more educated Medicare recipients are concerned that the benefits for that program will be scaled back (and there are unquestionably threats to do so!) but this does not justify opposition to extending those benefits to the rest of the country.

A new set of problems is described by Robert Pear in the New York Times, on Sunday, November 21, 2010, “As health law spurs mergers, risks are seen”. The focus of his article is the planned “accountable care organization” (ACO), a relationship between one or more hospitals (or “health systems”), doctors, nursing homes, and home health care agencies. The idea behind creating ACOs is that, by coordination of care and sharing of information, people’s health can be improved and money can be saved. There is a lot of sense to this approach. If a patient is discharged from a hospital to home, or to a nursing home, and there is more sharing of information with the home health agency, or nursing home, or the primary care doctor who will be responsible for care when they leave the hospital, there is greater likelihood that there will not be lapses in the patient’s care. Similarly, if the person’s health deteriorates to the point of needing to be re-admitted, it would be best if 1) all that could have been done in the non-hospital setting to possibly prevent that from happening was done, and 2) all the information about what was done was transmitted to the hospital.

The organizations most cited by health reformers as having been successful in controlling costs and improving quality are those that are already “integrated”, where the system that owns the hospital(s) also employs the physicians and controls the nursing homes and home health care agencies, or else has very close and dependent financial relationships with them, such as Intermountain Health Care, Geisinger Health System, and Kaiser-Permanente. Information – and money, including money saved by having fewer expensive readmissions, is shared among the various participants. So ACA creates financial incentives for others to create such relationships, the ACOs. The issue raised in Pear’s article are that many forms that these ACOs might take run the risk of violating existing laws that are in place to prevent kickbacks, monopolistic practice, and other forms of corruption. For example, it is illegal for a health system for offering contingency payments a physician who is not an employee – such as for admitting patients to the hospital, keeping stays shorter, etc. This makes sense too.

So we have two conflicting things that “make sense”: greater collaboration and aligned incentives can create greater efficiency and save money, but they can also lead to oligopoly and corrupt relationships. Monopoly is more efficient, but creates the opportunity for exploitation. Modern business practices, based on the work of people such as W. Edwards Deming[1], emphasize the importance of long-term relationships with suppliers so that they can learn and better meet your needs over time, something there would be no incentive to do if doing so cost them money, and you were likely to pull your business the next year because someone else bid lower. Governments usually have policies requiring contracts given to the lowest bidder, but there is a danger that the work will be of lower quality.

Much of the criticism of ACA from the “right” has been about lack of “choice”, but as we look at implementation of the health care law, we need to be careful that ideology does not trump actual health outcomes. Two recent studies show the risks of the “law of unintended consequences” of policies that encourage consumer choice and a market approach to health coverage. In “Health care use and decision making among lower income families in high-deductible health plans”[2], Kullgren and colleagues demonstrate that, in fact, as might be anticipated, poor people who choose to spend less out-of-pocket money by enrolling in such high-deductible plans pay the price later in not accessing health care and having poorer outcomes. Millet, et al, in “Unhealthy competition: consequences of health plan choice in California Medicaid”[3], show that, perhaps less intuitively, Medicaid (Medi-Cal) patients in California counties where they have a choice of plans are less likely to be enrolled all year than where they do not have such choice, and “Potential benefits of health plan choice may be undermined by transaction costs of delayed enrollment, which may increase the probability of hospitalization for ambulatory care-sensitive conditions.”

Ideally, a single-payer, Medicare-for-all, system eliminates the risks that people will not enroll or have gaps in enrollment, that there will be people left out, that people will, for understandable and reasonable short-term financial reasons, make choices that can have long-term adverse effects on their health, and that there will be different standards for quality of care for people with different insurance. But even that does not address the system of provision of care. The ACA law seeks to encourage communication and efficiency, but critics see danger in merger and oligopoly, which could limit options for consumers and in itself create risks to health care access and quality.

What could the solution be? One might be to have cooperative relationships with open-source access to information. Thus, your health information would not be in the control of a given hospital, health care system, or doctor, but rather be controlled by you, and made available to whichever provider – hospital, doctor, nursing home, etc. -- that you chose to provide your care. The information would not be in proprietary electronic medical record format, but rather in an interoperable format that could be utilized by any provider. Incentives could exist globally, not simply within a single organization, to produce the highest quality care rather than the highest profit margin. This would be an excellent example of real competition.

[1] See Mary Walton, The Deming Management Method, Berkeley Publishing Group, New York (originally published Dodd Mead, NY, 1986).[2] Kullgren JT et al., “Health care use and decision making among lower income families in high-deductible health plans”, Archives of Internal Medicine, 2010;170(21):1918-25. (Hyperlink is to abstract as full text not available free on line.)[3] Millet C, Chattopadhyay A, Bindman AB, “Unhealthy competition: consequences of health plan choice in California Medicaid”, American Journal of Public Health Nov2010;100(11):2235-40. (Hyperlink is to abstract as full text not available free on line.).

Sunday, December 12, 2010

In an Associated Press story from November 28, 2010, “Tax break for employer health plans a target again” (it was widely picked up; here I’ve given the link to the Pensacola News-Journal), Ricardo Alonso-Zaldivar writes about the resurgence of interest in eliminating the employer tax break for contributions to employee health plans. This proposal, put forward from time to time, has been given new prominence by the recommendations of Erskine Bowles and Alan Simpson, the. not dumb and dumber but right-and-righter co-chairs of the President’s task force on deficit reduction, which they have morphed into a task force on cutting taxes. For Bowles and Simpson, it is one of only a number of proposals they make that would take away middle-class tax benefits, and not even the least popular: that honor would almost certainly go to the elimination of the mortgage interest deduction.

The employer’s ability to deduct contributions to their employees’ health insurance goes back to the post-World War II era, when there was tremendous competition for workers (imagine that!) and wage and price controls made it impossible for businesses to compete on the basis of pay, so fringe benefits – specifically health insurance – became a real perk. The unions liked it because they could bargain for this benefit for their members. The losers, of course, were all of us, who did not get a national health insurance program. And for many years this benefit has been a real advantage to being employed by a company with a collective bargaining agreement, and clearly unions will strongly oppose any effort to make it more difficult for them to achieve this benefit.

Meanwhile, some Medicare recipients, concerned about maintaining one of the few benefits the elderly still have, have come out against much of the health reform bill. Many of the most vocal opponents are the wealthy elderly, but unfortunately many middle- and working-class seniors are in this group. This is the subject of James Surowiecki’s piece “Greedy Geezers?” in the New Yorker, Nov 22, 2010, as noted by Tallgrass Activist David Kingsley. While the title might be offensive, many of his points are well taken: “There’s a colossal irony here: the very people who currently enjoy the benefits of a subsidized, government-run insurance system are intent on keeping others from getting the same treatment.” One example of what seniors can see as real cutbacks to their benefits are the cuts to the Medicare Advantage program. Medicare Advantage (also known as Medicare Part “C”) is a program that basically takes your Medicare payment, and an additional payment from you, and enrolls you in an HMO that provides you benefits beyond that which traditional Medicare offers (such as glasses, hearing aids, a better drug benefit, especially before Part “D” was enacted). It was created by the Reagan administration as a way to, at least in part, privatize Medicare, and was accompanied by higher payments from the federal government to these insurers than was spent on traditional Medicare beneficiaries. This was a corrupt program that ACA was right to eliminate, but because those seniors enrolled in it were getting a benefit, they receive a cut. Of course, the cut (appropriately) is much greater to the insurance company, which was getting most of the benefit (the extra benefits received by the enrollees were worth much less than the insurance companies were being paid).

What a great example of divide and conquer! Bowles-and-Simpson’s (now they are one, ostensible bipartisanship aside) proposals, while they were supposed to be about deficit reduction, are all about decreasing taxes. And especially decreasing taxes on the wealthiest Americans and corporations, a strategy that has been demonstrated by the last decade to be extraordinarily beneficial to – the wealthiest Americans and corporations. Trickle down economics, decried by George HW Bush as “voodoo economics” during the 1980 election, are no less so now, although to call them that insults voodoo. Interviewed on NPR’s “All Things Considered”, Bowles-and-Simpson are asked about the criticism of their proposals by economist and NY Times columnist Paul Krugman, who says it is about redistributing wealth upward. While Simpson says Krugman has “lost his marbles”, he doesn’t address Krugman’s criticisms.

The fact is that the wealthiest are doing great and everyone else is being penalized. This cannot be justified by any reasonable economics, voodoo, trickle-down, Friedmanesque or anything else. The elite have a Congress that they have bought and paid for, as discussed in his November 28, 2010 column, Still the Best Congress Money Can Buy, by the NY Times’ Frank Rich. He refers us to recent Times articles documenting the recent enormous corporate profits (“Corporate Profits were the highest on record last quarter” by Catherine Rampell, November 23, 2010) and profligate spending by the Wall St. “masters of the universe”[1] (With a Swagger, Wallets Out, Wall Street Dares to Celebrate, November 23, 2010, by Suzanne Craig and Kevin Roose), while the Times’ editorial page reminds us that while they grow wealthier regular people, who still can’t get jobs, also can’t even get their unemployment benefits extended (The Unemployed Held Hostage, Again, November 28, 2010).

Our health system has long been terrible, in lack of equitable access for many while there have been enormous profits for the insurance and pharmaceutical industries, in excessive interventions and procedures for the well-insured masquerading as the “best health care system in the world”, quantity masquerading as quality even for those who have had health coverage. As developing countries such as India seek to develop their own health systems, the US is notable as a model for what should not be done (see the interview with Nobel-prize winning economist Joseph Stiglitz in the Times of India'The US model of private health insurers is inefficient, expensive' (thanks to Don McCanne in his wonderful Quote of the Day). The ACA was a first step to fixing it, but scarcely a final one. It is time to stop talking about how to inflict more economic pain on the bulk of Americans, unemployed and working, until we stop giving the store away to the elite.

Surowiecki notes that “seniors think of Medicare as an “entitlement”—something that they have a right to because they paid for it”. Why not? Even though he notes that today they “get far more out of Medicare than they ever put in,” he adds, appropriately, that “There’s nothing wrong with this: the U.S. is rich enough so that the elderly shouldn’t have to worry about having health insurance; before Medicare, roughly half of them didn’t have it”. He’s right on that. And we all should have it – Medicare for all, coverage for all of us. After 45 years of it working for seniors, it is time for it to be an entitlement for everyone. Something, finally, for the 99% who are not the “masters of the universe”. Sounds good to me.

[1] A phrase coined by Tom Wolfe to refer to Wall St titans in his 1987 book The Bonfire of the Vanities, Farrar Straus and Giroux..

Friday, December 3, 2010

This event is free and open to the public. For more information and to RSVP, contact Nancy Michaels at nmichaels@roosevelt.eduMatthew Freeman LECTURE & SOCIAL JUSTICE Award

GENDER DIS-INTEGRATION AND THE DISCIPLINE OF “LGBT” A TRANSFEMINIST PERSPECTIVE -- Anne Enke

Monday, December 6 11 a.m. - 12:30 p.m.

Roosevelt University, Chicago, IL

430 S. Michigan Ave. Sullivan Room - 2nd FloorMatthew Freeman was a Roosevelt student committed to working for a world with true justice, equality and fairness. Matthew died days before he would have received his degree. Through the support of his parents, his legacy continues with this annual lecture and award presentation. This year’s Matthew Freeman Social Justice Awards will be presented to Roosevelt students Oneka Ijeoma and Renee Farwell for their commitment to bettering our world through activism. The Mansfield Institute for Social Justice and Transformation and the Department of Political Science and Public Administration present the annual Matthew Freeman Lecture and Social Justice Award Ceremony.

This year’s distinguished lecturer is Anne Enke, Professor of Gender and Women’s Studies, History and LGBT Studies at the University of Wisconsin. Professor Enke is the author of Finding the Movement: Sexuality, Contested Space and Feminist Activism (Duke University Press, 2007).

Monday, November 29, 2010

.Not long ago, I wrote of the “consumer alliance” between the American Academy of Family Physicians (AAFP) and the Coca-Cola company (The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010). In that piece, I also noted the close relationship between the American Dietetic Association (ADA) and Hershey’s. For the record, I did not believe that these were, um, healthful, for the American people. I cited the work of Howard Brody, who looked at the ethics of the conflict of interest specifically in the Coca-Cola/AAFP case (and yes, there is definitely a conflict of interest whether or not that conflict results in prejudicial outcomes).

It turns out that this kind of arrangement is not limited to the United States. Indeed, Dr Alex Scott-Samuel, Director of EQUAL (Equity in Health Research and Development Unit) in the Division of Public Health at theUniversity of Liverpool, brings our attention to an article in the British newspaper the Guardian. It reports that in the United Kingdom, the “…Department of Health is putting the fast food companies McDonald's and KFC and processed food and drink manufacturers such as PepsiCo, Kellogg's, Unilever, Mars and Diageo at the heart of writing government policy on obesity, alcohol and diet-related disease”, an apparently far more malignant development.

The potential advantage of a government-run national health system is that it can insure that health care is provided for everyone, as I have often lauded. The public health role, however, is one that is even more commonly a public one, even in the United States, but in the UK the influence of the Department of Health over public health policy is even greater than in the US because they do not have independent state governments with their own health departments and health policies. We are, of course, familiar with the “fox guarding the henhouse” method of making public policy, which seemed to have reached its apex in the GW Bush administration with the big oil companies writing energy policy. Or maybe not; recently we discovered from a recent NPR investigative report (we need more of those) that the noxious Arizona immigration law was actually written by the private, for-profit prison industry as a way to increase business! (“They even named it. They called it the 'Support Our Law Enforcement and Safe Neighborhoods Act.’")

Is, then, the public’s health just another example of this type of “consumer alliance” (I really love this term!) – the British call them “responsibility deals”, more enigmatic, perhaps, but not more accurate – or is it another matter? Clearly, as demonstrated by the BP oil spill in the Gulf of Mexico, energy policy is critically related to health. And a law that makes it illegal for a person, a US citizen, to stop an offer humanitarian life-saving help to someone they find wandering and half-dead in the Arizona desert, not to mention imprisons and deports those who are not legally here, impacts on their health. Certainly these policies impact the rest of their lives.

Maybe it is because this is happening in the UK that makes it stand out. Maybe because some of us, myself included, have seen the UK and other European countries (and certainly there are many differences between European countries) as more focused on the health of their citizens. I know that there have been any number of problems with and criticisms of British health and social policy, including those of Julian Tudor Hart (“the inverse care law”[1], Medical Student Selection, December 14, 2008) and Sir Michael Marmot (the “Whitehall studies”, Health Outcomes: The interaction of class and health behaviors, May 9, 2010), and continued by current public health experts and scholars. I guess that the presence of the British National Health Service and its universal access have been so overwhelmingly positive in this regard that I have regarded such criticisms as those of people who “don’t know how good they have it”. Let me be clear: I never doubted that the concerns were valid, but rather that they may minimize the good things present in the system; in the same way I know that those in US cities with public hospitals are correct when they point to the underfunding, second class care, and inequities that they suffer, but at least, unlike where I live, they have public hospitals.

This initiative is, clearly, malignant. It is unquestionable “conflict of interest” for those whose interest is in selling more of their products, however unwholesome they may be, to be involved in the writing of public health policy around the use of, and advertisement of, those products. And, moreover, they will certainly ensure the insertion of policies that benefit themselves at the same time as they harm the public’s health. Note that it goes beyond food (and junk food); not only does the “food network to tackle diet and health problems includes processed food manufacturers, fast food companies,”, but “The alcohol responsibility deal network is chaired by the head of the lobby group the Wine and Spirit Trade Association.” Wow. One consumer advocate noted "This is the equivalent of putting the tobacco industry in charge of smoke-free spaces." It’s quite an achievement. Even Philip Morris couldn’t get to chair the cigarette control board!

Obviously, that this is occurring shortly after the Conservative Party has taken control of the British government is not a coincidence. It is part of a very successful strategy to transfer not all most, but virtually all, wealth and power to those who are already most wealthy and powerful. In the US, despite the control of the White House and both houses of Congress by the supposedly more progressive Democratic party, this consolidation is proceeding apace, clearly helped by Supreme Court decisions such as Citizens United that essentially removed all limits on corporate contributions to political campaigns.

Having input from corporations that stand to benefit from legislation or policy is one thing, as long as it is balanced by input from consumer groups – and the welfare of the people is the final criterion for making a decision, not maximizing corporate profit. In this case, the case of the public’s health, the decision should be clear cut.

Tuesday, November 23, 2010

.In a rather unusual action, the National Cancer Institute (NCI), a division of the National Institutes of Health (NIH), issued a press release on November 4, 2010 announcing preliminary findings from a research study that, at that time had yet to be published (it since has been). This bulletin, Lung cancer trial results show mortality benefit with low-dose CT, announces that a large, multi-center, randomized controlled trial (RCT), called, the National Lung Screening Trial (NLST), has found that regular screening of current and former heavy smokers with low-dose chest computed tomography (CT) scanning aged 55-74, compared to screening by regular chest x-ray, led to 20% fewer deaths from lung cancer. It is unusual in that it is there is no associated published study in a journal describing these results (the statement says that it is being “prepared for publication in a peer-reviewed journal within the next few months”); the only concurrently published article is a description of the methods of the NLST study, with discussion of previous screening studies for lung cancer, is the “National lung screening trial: overview and study design” published in the November issue of Radiology and made available November 2, 2010.

The study comparing these two screening tests – x-ray and CT – appears very strong. Because it is randomized, there is no significant difference between the pre-existing characteristics of those assigned to CT versus chest x-ray screening, and because the end point is death, it largely eliminates one of the most important confounding issues in prior studies called “lead time bias”. This means that if a more sensitive test identifies cancer earlier in its course, the time between diagnosis and death will be longer even if the death itself is not forestalled. (E.g., you have cancer and one test finds it at 55 and you die at 60; another test could find it at 50 and you die at 60; finding the cancer earlier didn’t make you live longer.) It is also a very large study (53,000 people) and well designed in many other ways, so that a 20% reduction in death is important. There is an excellent FAQ for this study, including graphics of lead-time and length-time bias, at the NCI website

So is there any problem? Will lung cancer, the biggest killer among cancers, become like breast cancer, where a screening test can find the cancer earlier, lead to earlier and effective treatment, and decrease mortality? Not exactly. In addition to a 20% reduction in mortality being far less than the reduction in breast cancer mortality from mammography, lung cancer is not breast cancer; we know the cause of the vast majority of cases: smoking. The authors, and the NCI, emphasize that such screening, even if widely adopted, is no substitute for stopping smoking or increasing efforts to get people to stop smoking. The real question is what is the benefit of spending huge amounts of money (while there is no statement of cost of screening in either the NCI brief or the Radiology article, estimates are as much as $12 billion a year -- 30 million screened at $400 per CT screening with interpretation, including follow-up exams -- to screen people who smoke, or smoked, heavily for cancer in pursuit of a significant, but relatively small, reduction in mortality? Moreover, there is no estimate of the potential risk of repeated CT scans (even low-dose, such as studied) and the degree to which the existence of a screening test might decrease the interest of smokers in stopping. (If this seems perverse, it is almost certain to happen; it happens every time news of a possible preventive intervention is announced: some people decide there is no need to stop their risky behavior.) Thus, to save 1 in 300 lives (about 100,000 of the 30 million screened, or 0.039% of the US population), not even considering quality of life (generally low for long-term smokers with cancer who have other conditions such as chronic lung disease), will cost about $40 per every person in the US per year.

How do we evaluate cost-benefit? In the current political environment, the popular theme is “don’t spend public money”, but there is always the implicit caveat “except if it benefits me” – and in this country we have over 300 million “me’s”. Dr. Robert Bowman, who has previously contributed to this blog, describes for us the potential alternative uses of not only the ongoing cost of screening, but even the cost of the study itself:

· $250 million is the entire sum that the Health Resources and Services Administration (HRSA, the government agency that funds workforce research, training programs in primary care, dentistry, physicians assistants, pipeline programs, etc.) could scrape together to address emergent needs for primary care workforce this year.

· $250 million, if used to train family doctors at about $30,000 cost per Standard Primary Care provider, would produce 8333 Standard primary care years of workforce in family medicine graduates, or about 333 FM physicians serving their entire careers and improving cost, quality, and access where it is most needed.[1]

And the $12 billion?

· The $12 billion a year spent on CT screening for 30 million current or former smokers could graduate 16,000 family physicians a year.

· $12 billion a year, expended each year for the 30 years required to actually build any workforce (i.e., a generation), if applied to family medicine would supply the entire nation enough primary care for all locations and populations in need of primary care. Sufficient primary care for over 90% of Americans in all needed locations would begin 30 years after reaching 16,000 annual graduates and would be maintained with continued funding of 16,000 annual graduates. (Indeed, compared to less-efficient spending on training programs, such as internal medicine, that yield far fewer primary care years per dollar spent, this $12 billion is actually is a savings of a few billion dollars!)

Or, if we are concerned about lung cancer, using this for tobacco control campaigns, both the "stop smoking" kind and the legislating non-smoking venues, cities and states.

Dr. Bowman continues:"The US continues to fail, time after time, in the most basic choices regarding care for Americans most in need of care. The US can focus on the health care needed for nearly all people nearly all of the years of their lives in nearly all locations or the US can continue to spend its $7000 per person ($2.5 trillion) on the health care needs for only some of its people for a only a few years of their lives, with health care delivery services concentrated in only a limited number of locations (4% of the land area).

There is little point to research about rural workforce, health access, or primary care until the nation makes a decision to quit sending health care spending to locations with top concentrations for the care of Americans already with the most care."

Any economist – or wise investor or businessperson – can tell you about “opportunity cost”. This means “if you spend money on one thing, you can’t spend it on something else.” Therefore, the benefit of what you spend money on needs to be looked at not only for its intrinsic value (“will spending $12 billion a year on lung cancer screening with CT save lives?”) or against a very limited range of options (“Is it more cost effective than screening with chest x-rays?”) but weighed against reasonable alternative strategies to improving the health of people – all people.

Dr. Bowman gives strong arguments for the benefit of investing in primary care workforce development, and particularly in family medicine. Maybe there are other strategies for most improving the health of most of our people. But looking at new scientific advances in isolation is clearly a flawed approach.

[1] For a detailed description both of this measure – standard primary care (SPC) years – and the reasons that Family Medicine, as opposed to other physician and non-physician primary care training (internal medicine, pediatrics, physician’s assistants, nurse practitioners) is the most efficient producer of SPC years, see Ten Biggest Myths Regarding Primary Care in the Future, January 15, 2009..

Wednesday, November 17, 2010

.A major focus of public health, about which I have written several times, is addressing the disparities in health arising from modifiable conditions (such as inequality of opportunity, income, and racial and ethnic differences). While it is common for those with privilege – wealth, health, opportunity – to believe that they have these privileges because they are “deserving”, i.e., because of their hard work, education, etc., such an outlook minimizes the critically important fact that there are lots of people who work just as hard and have very little. The “illegal immigrant”, working 3 minimum (or sub-minimum) wage jobs to try to just keep his or her family fed and housed, is not only not lazy, but working a lot harder than many of us who are able to enjoy weekends off, play golf, watch the kids’ sporting events.

So it is clearly not hard work alone. It is very much influenced by where you start, and what your opportunities have been. These are the social determinants of health (e.g., Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010) and the capability that people have of acting in healthful ways (Capability: understanding why people may not adopt healthful behaviors, September 24, 2010). It is common for people who have a lot to minimize, rather than to emphasize, the degree to which their position at the start of the race has affected their current position. Attacks on those who would seek to redress some of the most egregious inequities are still couched in terms of “economic class warfare” by those who have already won the war. Those with privilege are very concerned about change that would leave them with less of a leg up; they may give lip service to Horatio Alger heroes, but are more likely to wish to follow the model of George W. Bush. “If you’ve spent your entire life with the wind at your back,” a wise sage once noted (and I do not know to whom to attribute it), “a calm day seems unfair”. In terms of health, the connections are very clear. It is good for your health to be born rich. The Horatio Alger hero, pulled up by their own bootstraps, has worse health outcomes than the child born to privilege.

Health disparities, then, are real and important. But why should we – should anyone – be concerned about the disparities in physician income? After all, even the more “poorly” paid specialists, in primary care, make far more than the average American. Yes, they have worked hard to get into and through medical school and residency training, but, just as noted above, so have a lot of other people who will never make nearly as much. The problem is that, if the presence of a larger number/percent of primary care physicians is associated with improvements in the health of the population, and if the presence of wide disparities in income significantly influence students to choose higher paid specialties instead, then these disparities in health status are likely to continue and the overall health of the American people is likely to suffer. There is good data on both counts. Many of the posts in this blog have addressed the first, the positive influence of primary care on the health of the population (e.g., Lower Costs in Grand Junction: More Primary Care, Less High Tech, October 18, 2010; Primary Care, IMGs, and the Health of the People, August 14, 2010; and many others) and on health disparities[1]. I have also addressed the other point, the decrease in the number of students choosing primary care careers (e.g., Primary care specialty choice: student characteristics, July 12, 2010; Primary Care’s Image: A Problem?, November 17, 2009, and others).

A study published in the Archives of Internal Medicine by Leigh, et. al, “Physician wages across specialties”[2], is the most recent effort to quantify the differences. They utilized the large Community Tracking Study (CTS) of physicians from 2004-2005 to gather information on physician income. They grouped the physician responses into 4 broad categories (surgical, internal medicine and pediatric subspecialties [IMPSS], primary care, and other) and again into 41 specific specialties. They went beyond previous studies to calculate gross personal income on an hourly basis (thus controlling for hours worked per week) and did further adjustments to control for other variables, principally sex and age. They used a statistical manipulation to estimate incomes above the maximum set for the CTS (for some reason set at $400,000, much lower than many subspecialists make).

The outcomes were not surprising in comparison to previously reported data. In the 4 broad-group comparisons, primary care physicians averaged about $60/hr compared to IMPSS at $85, other medical at $88, and surgical at $92. In the single specialty comparisons, General Surgery was taken as a reference being actually near the middle ($86/hr), with the top incomes in neurosurgery ($132), radiation oncology ($126), and medical oncology ($114). At the bottom were family practice, general practice, general internal medicine, geriatric medicine, internal medicine/pediatrics, and “other” pediatric subspecialties (whichever those may have been) with a range of $50-$58.

There are several reasons to think that differences are, in fact, greater than those reported. There was only a 53% response rate to the CTS, and so we do not know if non-respondents made more, less or the same as respondents. “Hospital-based” specialties, specifically anesthesiology and radiology, which are among the highest-paid, were excluded. Other high-end specialties, such as cardiovascular surgery or transplant surgery, do not appear as specific specialties, and may have their incomes hidden when grouped with “thoracic surgery” or “other surgical specialties”. There are many sources of income for many physicians, including a variety of expenses that can be paid by practices and which would presumably be greater for higher income practices. Many highly-paid specialties are paid by hospitals directly (such as anesthesiology and radiology) or through “physician service agreements”. The correction used by the authors of the study for incomes over $400,000 could have been inadequate; certainly anecdotal experience in many locations would suggest that considering $400,000 as a reasonable top end for the highest paid physicians would understate that by at least half.Nonetheless, the income differences, even in 2004-05, were impressive. Given the debt load that medical students (particularly those, obviously, from the less wealthy families) graduate with, the significant attraction to higher pay is clear.

The Wall St Journal, in two recent articles (“Secrets of the system”) published October 26, 2010, looked at the Relative Value Update Committee (RUC), a group of 29 physicians convened by the AMA from different specialty organizations that make recommendations to Medicare on how to pay physicians for their, well, relative value. One, “Physician panel prescribes the fees paid by Medicare” by Anna Wilde Matthews and Tom McGinty, describes how this group meets to divide up a pie that Medicare seeks to keep constant. In the other, “Dividing the Medicare pie pits doctor against doctor”, Matthews discusses the contentiousness that happened when primary care physicians (greatly outnumbered) challenged their surgical colleagues to get a higher portion of the money (that is, to revalue activities done by primary care physicians relative to surgical specialists).

In the same issue of Archives of Internal Medicine that Leigh’s article appeared in, Federman and colleagues[3] surveyed physicians about whether they thought reimbursements were inequitable or not; 78.4% agreed that they are, with not that much difference between generalists and subspecialists. However, when the idea of shifting payments from subspecialists to generalists was raised, there was a marked difference; 66.5% of generalists supported this, while only 16.6% of surgeons did; overall 41.6% were supportive and 46.4% were opposed. That is, for most specialists, paying generalists more is ok, but paying themselves less is not.

The WSJ‘s Matthews quotes an email from Jonathan Blum, deputy administrator for the Centers for Medicare and Medicaid Services (CMS) saying that the Medicare agency is moving to “improve Medicare's physician systems to correct historical biases against primary-care professionals." That needs to happen. The changes need to be dramatic. And they need to happen soon.

Thursday, November 11, 2010

.I recently attended a Forum on health reform put on by the Sunflower Foundation of Topeka, Kansas in Lawrence. The keynote speaker, John McDonough, PhD, gave an excellent rundown of the contents of the ACA health reform law. Prior to that a panel of experts from state government, that included Sandy Praeger (a Republican), Kansas Insurance Commissioner and former chair of the National Association of Insurance Commissioners (NAIC). She made it clear that the requirement that large insurers spend 85%, and small ones 80%, of their premiums on actually providing health care (infamously known as the “medical loss ratio” in insurance circles) will be taken seriously, and that insurance commissioners in NAIC, which is the group charged with making the recommendations on this issue to HHS, will not blithely allow insurers to load lots of costs not obviously related to patient care (like marketing and paying the folks that deny your claims) into this bucket. Other participants included Andy Allison, head of the Kansas Health Policy Authority, a governmental agency that, in addition to doing health policy runs the state Medicaid program, and several people from area foundations and consumer advocacy groups. One might have thought, listening to the discussion, questions from the audience (largely health advocates and professionals), and the responses to them, that Kansans are not only thoughtful but caring, worried about the health of their neighbors and fellow citizens, and hoping that health reform will really bring about positive change.

So, all the rest of you non-Kansans, keep this in mind when you see who we elect to statewide office, to our legislature, and to Congress. They don’t represent everyone in this state. Maybe their positions don’t even represent their own beliefs but rather crass political calculations. Or, perhaps, financial calculations; looking at where the big contributions are coming from, and serving the interests of those donors.

As panelists discussed what they saw as important parts of ACA, I was struck by the comment of one person, representing a consumer group, that a big way that ACA would save money would be in Medicare not paying for hospital re-admissions. (Actually, the term, in Section 3025 of the ACA, Public Law 111-148, p. 290, the term is “excessive” readmissions.) The assumption here is that the re-admission was a result of inadequate care on the previous admission, premature discharge (motivated, presumably, by the length of stay guidelines that are widely in use by organizations such as, say, Medicare!), etc. This is an attractive idea; after all, if you bring your car in to be fixed, and it breaks down shortly thereafter, should you pay for the second visit to the mechanic? (She didn’t say that; it is my metaphor.)

But, of course, only if it for the same problem, right? Not if the first hospitalization was for a broken leg, and the second for heart failure. After all, if your car had its brakes fixed and the transmission goes 2 weeks later, it is not the mechanic’s fault. Unless, maybe the second hospitalization was for a complication of the first, like say a blood clot in the lung. Especially if the patient was not given proper clot prophylaxis the first time. But what if they were given that prophylaxis and the clot happened anyway? It is not always so simple.

It is not always so simple even when the re-admission is for the same problem. People with advanced chronic diseases have advanced chronic diseases. They can be treated as outpatients, but will frequently decompensate, and require hospitalization. Remember Red, Blue, and Purple: The Math of Health Care Spending (October 20, 2009)? This is one of the main groups comprising the 5% of people who use 50% of the health care dollars; even when they are brought into the hospital and “tuned up” (yes, this automotive phrase is in fact used), even, or especially, when they have spent time in intensive care, they get sick and require hospitalization again. Their body is dying, but modern medical care can do remarkable things to forestall that death, to patch folks up, to send them back home, or to a nursing home -- for a while, until their body resumes its inevitable decline; the closer a person in this condition is to dying, the more frequent the readmissions. To continue the automotive metaphor, it is one thing to bring in a 3 year old car for new brakes and have them begin to fail 2 weeks later and bring it back; it is quite another when the car is 15 years old, has multi-system failure and won’t run, but the great mechanic can patch it up so you can drive it off – when it fails again in 2 weeks, is this the mechanic’s fault?

It is obviously unreasonable to say that you won’t pay the mechanic the second time, or for Medicare or other health insurance to not pay the hospital and doctors for the work they do on the re-admission. It might be reasonable to decide that the person, like the car, is not salvageable beyond the very short term and should not be readmitted, but this is a decision that can’t be made by the treating doctors and hospital, and it is unreasonable to not pay them when the patient returns because they did such a good job of keeping him/her alive the last time. When are these readmissions “excessive”?

So who should make the decision? Ideally, the patient, in consultation with family members or others s/he trusts, maybe even his/her doctor. This is, after all, the idea behind what we call “Advance Directives” such as Living Wills and Durable Powers of Attorney for Health Care. But not everyone has them, not everyone has even discussed their preferences with their family or their doctor, not to mention put their decisions down on paper so that those responsible for making decisions when s/he cannot have both something to guide them and, indeed, something that requires them to do it. Doctors are not paid to have these extensive discussions with people, although many of them do it anyway; the component of ACA that was going to reimburse for these discussions was struck after being maligned as (wrongly) being “death panels” that would “decide to kill your grandmother”.

But who should decide? If an elderly person is demented, cannot communicate, is in kidney failure and heart failure and has been admitted several times, including to intensive care, and kept alive by medical technology, who should decide if they will be readmitted from the nursing home when they get worse? Often the nursing home just sends them. If there is family, they are the ones who currently make these decisions, provided that they can agree. What if the patient cannot swallow without choking, but the family doesn’t want him/her to “starve” – should this person get a big central IV to give basic nutrition, or have a surgical procedure to feed directly into the stomach? The family does not pay, Medicare does. What would you decide? You would never do this to your parent or want it for yourself? Are you willing to be on the “death panel” that overrules the family? What about the similarly demented and sick person who has been admitted to the intensive care unit 3 times in the last year, amazingly “survived” to discharge, and finally, after several later readmissions, finally does die. And the daughter wants to sue because “somebody” must have done “something” wrong? Should we not pay the hospital? Should we tell the ambulance not to pick her up? Will you be the one to tell the daughter that the fact that she has obviously unresolved issues, and that she should have accepted during the first 6-week ICU stay that her mother was going to die soon?

I hope you will be. I hope you will be out there, helping support the healthcare professionals to make the right decisions, not because Medicare is paying but because they are right. And help us to figure out what the right decisions are. While all of us feel differently about those close to us than about strangers, "save money on them, spend it on me!" is not a reasonable, or moral, strategy. .

How is this so? This is because over 90% of the family medicine residency programs in the nation are located in urban areas, and only 7% in “large rural areas”; it is very hard to have a program entirely in a “small rural area” as the requirements for family medicine training include a great deal of time spent in the hospital and working with other specialists. Nonetheless, the authors surveys discovered that nearly half of the family medicine programs felt that training rural doctors was an important part of their mission.

From the Executive Summary: “Rural residency programs provided a higher proportion of rural training than urban programs, but because more programs were in urban settings, there was more rural training in urban than rural programs. Overall, 15% of respondents had a formal RTT [rural training track]; of these, 61% were in rural and 10% in urban programs. Rural residency programs conducted 83% of all rural residency training in RUCA[2]-defined rural areas. Comparing the 2000 and 2007 surveys, rural training increased from 372 to 408 FTEs, but rural training in urban programs declined from 186 to 79 FTEs, resulting in an overall decrease in the amount of rural-focused family medicine training.” See figure for example of a “RUCA map” in a state (Kansas) with a high percentage of “isolated rural” areas; Other states (say, New Jersey) look different!

The authors found that while virtually all (99.9%) of the training FTEs reported as rural in rural programs in fact occurred in rural (RUCA-defined) areas, only 21.7% of those reported by urban programs were in such areas. The net result was that only 7.3% of family medicine residency training FTEs are in rural areas, with 83% of these conducted by rural programs. Interestingly, to me, a higher percentage of urban programs listed rural training as “very important” (45.3%) than listed urban (underserved) training (40.4%).

The authors discuss the policy implications of this situation, including the possible impact of several components of the ACA health reform law that encourage training in rural areas. An important one has to do with Medicare funding of GME (residency) positions, the arcane but major source of funding for such training (Funding Graduate Medical Education, May 25, 2009; Public Law 111-148, Sect 5506, p 661). The change would make it easier for non-hospital sponsors of training (such as community health centers, an area the authors have also written about[3]) to receive this funding (Public Law 111-148, Sect 5508, p.668). The law – and policy – also favors redistribution of unfilled GME spots to rural hospitals. However, there are counterpressures: many big urban hospital training sites are “over their cap”, meaning they have more residency positions than are funded by Medicare. In these cases, the hospital, or another entity, funds the positions; these are virtually always in those specialties that make more money for the hospital, not in primary care, and certainly not in rural tracks (Primary Care and Residency Expansion, January 7, 2010 ). As they expand, in response to the demand for more physicians and medical school class increases, they will exert great political pressure to have new GME slots assigned to them to help cover their costs.

So here is the situation:· There is a tremendous shortage of doctors in rural areas.

· Rural family medicine training programs, particularly those located in rural areas, are very effective in producing physicians who will practice in those rural underserved areas.

· Only 7.3% of family medicine (FM) residency positions are in such rural programs. This is way better than any other specialty, and may in fact be higher because while the authors did not count many of the trainees claimed as rural by urban FM residencies because they are not actually occurring in RUCA-defined rural areas, “Training locations may be defined as 'urban' using RUCA definitions but may still be sparsely populated and serve a predominantly rural patient populations.”

· Even if all FM positions claimed by their sponors as rural are in fact so, FM residents are only about 10% of all residency positions (2,630 of 25,500 in 2010), and virtually no other residents are trained for, not to mention likely to enter, rural practice…despite the need for other specialists, especially general surgeons, in these communities.

· ACA has a number of components that target an increase in the production of rural physicians (particularly family doctors and general surgeons, Public Law 111-148, Sect 5501, p. 534), but even if these are fully implemented, and taken advantage of by students, it will be many years before they have a significant impact.

· Despite these ACA changes, there will be counterpressures to use many of the new training slots for training non-primary care residents in urban sites, and particularly in academic health centers; these will come from both the academic health centers and their teaching hospitals themselves, the subspecialty physician medical societies, and the medical students themselves who overwhelmingly prefer to live in urban areas, as well as to earn the much higher incomes of subspecialists.

How might this be changed or modified? The provisions in the ACA law funding of GME slots to non-hospital settings such as community health centers, preferentially training primary care doctors (and general surgeons), and supporting the growth of community health centers and health extension services are a start, but they are not sufficient. The key is going to be greater incomes for doctors practicing primary care and general surgery in rural areas compared to those practicing subspecialties in urban areas. Supply and demand is insufficient; while there is demand for such doctors in rural areas, there is demand for more subspecialists by urban hospitals that see them as cash cows. Medicare sets reimbursement rates, as almost all payers model their rates as percents (usually higher) of Medicare’s. The reimbursement has to change so dramatically as to make primary care doctors in rural areas make, if not more, at least not nearly so much less as subspecialists in cities.

This financial change will begin to level the playing field. Medical students who have no interest in rural practice can still stay in urban areas, and even in subspecialties, but they should have to pay a financial price, making less than they would if they were to practice in what (to them) might be considered a less desirable area. As long as we make some careers pay a lot more, often for no more or even less work, as well as be located more popular (urban metropolitan) areas, we cannot expect any different outcome from the one we currently have.

[1] Chen FM, Andrilla CHA, Doescher MP, Morris C, “Family Medicine Residency Training in Rural Locations”, Final Report #126, WWWAMI Rural Health Research Center, University of Washington School of Medicine Department of Family Medicine, July 2010.[2]RUCA = Rural-Urban Commuting Areas; a measure of population density that accounts for nearness to an urban area; obviously two counties may have similarly low population densities, but if one is surrounded by similar counties while the other is adjacent to a county with a large – or moderate – urban area, the first is “more” rural.[3] Morris CG, Chen FM, Training Residents in Community Health Centers: Facilitators and Barriers, Annals of Family Medicine, Nov2009;7(6):488-94